The news this week has been all about vaginas – specifically the idea of “seeding” a newborn’s gut with a swab from the vagina after a caesarean birth.

Vaginal Seeding after a caesarean birth was first widely covered in the film “Microbirth” which covered the work by Maria Dominguez-Bello and her colleagues, looking at whether the differences in gut bacteria between vaginally and caesarean born babies was due to the fact that caesarean born babies do not absorb gut flora from their mother’s vagina. Because these differences are linked to long term health problems, the research is attempting to find whether the swabs help to change the gut bacteria in a positive way.

The results of the pilot study were very positive, with the gut bacteria of 100% of the “seeded” caesarean-born babies being very similar to those of the vaginally born babies, in contrast to the caesarean-born babies who were not seeded where 100% of them had a different microbiome. The authors state that they don’t yet know whether this would impact the baby’s health over time, nor whether the results would replicate with a wider study group, and more work needs to be done.

Concerns have been raised about the risk of infection from vaginal seeding, and the original paper which triggered the media storm recommends not doing vaginal seeding following a birth which was planned as a caesarean specifically in order to reduce the risk of infection from, say, HIV or herpes. Surely this is self evident? There is also a question of whether pathogens such as Group B Strep (GBS) may put babies at risk – but as many as 1/3 of women carry GBS at the time of a vaginal birth, and there is no reason to think that this would be more readily passed on through seeding than a vaginal birth although this would be important to look at in future studies.

It has also been suggested that amniotic fluid may “wash” the vagina and change the flora experienced by babies passing through during birth compared with seeding the baby after a caesarean birth. The authors of the pilot found that there was no difference in a woman’s vaginal flora before and after birth, so this does not seem to be the case, and most babies do not simply flow down on a wave of fluid!

Perhaps one consideration is that babies are often born with their eyes and mouths closed, and so when considering vaginal swabbing, it would be useful to know whether the swab should be put into the baby’s mouth or eyes, or simply wiped over them. Timing of when is best to use the swab needs to be better understood, and the pilot study says that parents should be aware that skin to skin and breastfeeding are well understood to be extremely important to a baby’s gut health and long term health.

The pilot was very small, with only 18 babies in the study, and the authors are clear that more research is needed. This is contrary to much of the misleading media coverage which has stated that there is no evidence for vaginal seeding after a caesarean birth. There is, it’s just a very small sample study and is not sufficient to change recommendations.

I had a mole removed yesterday. Just a simple procedure, done in the GP clinic on a smooth running, efficient weekly service.

Before the doctor went anywhere near me with a scalpel, I was asked to sign a consent form because, of course, even when I ask someone to cut a piece off me, we all need to be very clear about what exactly I have requested, and what they have agreed to do. I’m quite fussy about consent forms. I like to know what I’m signing. I like to read all of the details and to ensure that I clearly understand what is being offered and what the potential risks may be.

Consent forms can often be long and complicated. This one wasn’t – it was a small piece of text on an A5 sheet of paper and the consent wording was along the lines of, “I agree that I have been fully informed of all of the risks, which may include bleeding, pain and scaring”. It reminded me of a self-discharge form that I was asked to sign in hospital once. It stated that, “I have been made fully aware of all of the risks of self-discharging”. However, the reason that I was self-discharging was that I had been in the hospital for two days without seeing a doctor once, my symptoms had gone and I was clearly low priority, as otherwise I would have already have had a discussion with the doctor, which would have meant that I was, in fact, fully aware of any risks of leaving. I hadn’t, so I wasn’t. I declined to sign that form and left anyway.

In AD 579, Emperor Justin II was in need of emergency surgery. No surgeon would even attempt the procedure because they were too worried about being blamed for it if it went wrong. Emperor Justin handed the surgeons the scalpel himself to clearly show his request for the surgery, and promised that there would be no retributions if they failed. In fact, he died, so it’s a good job that they did! This very early example of consent being gained for the surgeons’ protection rather than the patient’s, is now being repeated time after time in our hospitals and clinics. The time pressures on clinicians is such that it is extraordinarily difficult for them to walk us through the pros and cons of different options, and so often reduced to the effects of the paternalism endemic throughout history, where the likes of Henri de Mondeville in the late 13th Century stated, “patients […] should obey their surgeons implicitly in everything appertaining to their cure”, and even the Hippocratic texts which recommend, “concealing most things from the patient, while you are attending to him.”

While the lack of information sharing nowadays is almost always for entirely different reasons (a lack of time, not desire for control), we do see responses from medical staff when we ask for more information which perhaps many might get huge value from reflecting on. In my experience, impatience is the usual reaction, which again is likely to be because of time constraints, but sometimes there is perhaps a paternalistic throw back. For instance, I was once in a meeting with a consultant who was in discussions with a doula client. She had plenty to ask after much preparation between us. After she had gone through a number of her questions, the doctor asked in rather frustrated tones, “You seem to know an awful lot about this. Who have you been talking to?”

My client responded, “Well, my doula”

To which the doctor snapped back, “No, I meant which professionals?”.

So, to go back to my own minor surgery yesterday. I read the consent form and I pointed out that to sign to say that I was fully informed of the potential risks, without them all being laid out, was not full consent. The doctor replied that there was a list, look, right there, and anyway it’s just, he said, so that you won’t sue if there’s any issues. I explained that I meant that the wording itself implied that there were other risks that weren’t listed – I couldn’t blanket consent to say that I know everything – and, importantly from his perspective, he was unlikely to be protected if, say, he hit a tendon and caused me to lose function in my hand.

The next day I happened to be in the same GP surgery again for a physio appointment. Because my wound had bled quite badly, I asked the receptionist if she would be able to get me a replacement dressing from the nurse. “Oh no”, she replied, “you’ll have to have an appointment for that”.

“Why?” I asked. “It’s basically like changing a plaster, I can just do it myself”.

“Well,” she responded, “you might sue us if it’s been bleeding so I need to make sure that the nurse sees you to protect ourselves.”

Is this really where we have gone with obtaining consent? I cannot change my own simple dressing because I might sue for some minor bleeding that I’d already signed to say that I understood might happen?. On the one hand, are health professionals trying to desperately cover themselves with extensive notes, and consent forms which may or may not be adequate, and on the other hand completely unable to give people in their care the time to actually talk things through properly? What does obtaining consent mean? When women in the throes of labour are bullied in caesareans with long speeches about the dangers of continuing with their vaginal birth, and then they are given complex consent forms with risks such as “death” as they’re being wheeled towards the theatre, can we really say that they’re consenting? And in the end, who, if anyone, is being protected here?

Consent is not as simple as signing a consent form. Food for thought for both health carers and the people in their care.